Fillable Voluntary Self-Identification Of Veterans Form printable pdf download

Voluntary Self-Identification of Veterans

Definitions

This employer is a Government contractor subject to the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as

amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to

take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans;

(3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications

are defined as follows:

A “disabled veteran” is one of the following:

•

A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the

receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of

Veterans Affairs; or

•

A person who was discharged or released from active duty because of a service-connected disability.

A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's

discharge or release from active duty in the U.S. military, ground, naval, or air service.

An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military,

ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been

authorized under the laws administered by the Department of Defense.

An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground,

naval or air service, participated in a United States military operation for which an Armed Forces service medal was

awarded pursuant to Executive Order 12985.

Protected veterans may have additional rights under USERRA—the Uniformed Services Employment and Reemployment

Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you

may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty

if not for the absence due to service. For more information, call the U.S. Department of Labor's Veterans Employment

and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

Self-Identification

As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of

Labor each year identifying the number of our employees belonging to each specified “protected veteran” category. If

you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the

appropriate box below. If you are not a veteran, select box 1 OR select the box(s) that apply to your veteran status.

I am not a veteran. (I did not serve in the military.)

I belong to the following classifications of protected veterans (Choose all that apply):

DISABLED VETERAN

RECENTLY SEPARATED VETERAN

Military Discharge Date (MM/DD/YYYY):

ACTIVE WARTIME OR CAMPAIGN BADGE VETERAN

ARMED FORCES SERVICE MEDAL VETERAN

I am NOT a protected veteran. (I served in the military but do not fall into any veteran categories listed above.)

I choose not to identify my veteran status.

____________________________________________

__________________________________

Today’s Date

Your Name / Z#

Voluntary Self-Identification Of Veterans Form

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